Review Soft Tissue Augmentation With Dermal Fillers, Part 1: Lips and Lower Face Anthony M. Rossi, MD; Rajiv I. Nijhawan, MD; Maritza I. Perez, MD As the development of new technologies and treatment approaches continue to expand the field of cosmetic surgery, dermal filler injections have become increasingly popular, minimally invasive means of improving aesthetic appearance. New filler materials have improved the ease of use with longer- lasting results as well as minimal adverse effects (AEs) and downtime. The aging lower face features characteristic changes that are particularly amenable to treatment with fillers. In this article, we discuss techniques used for successful lip augmentation as well as rejuvenation of the lower face through correction of the perioral rhytides, marionette lines, and prejowl sulci with frequently used dermal fillers. Although most dermalCOS fillers are approved DERM by the US Food and Drug Administration (FDA) for treatment of lines and wrinkles only, we encourage a more natural approach using global assess- ment of facial aging to develop an individualized approach to volume restoration and rejuvenation. Do Not CopyCosmet Dermatol. 2012;25:260-265. he field of cosmetic surgery continues to changes that are particularly amenable to treatment with expand with the development of new tech- dermal fillers. The effects of facial aging include bone nologies and treatment approaches. Among resorption, loss of subcutaneous tissue, muscular atrophy, the newest developments are injectable der- and decreased skin elasticity due to loss of collagen and mal fillers, which have become increasingly elastic tissue. The process is unique in each individual Tpopular as a noninvasive means of improving aesthetic and can lead to varying degrees of vertical perioral rhyt- appearance, including the signs of aging. New filler mate- ides; downturned oral commissures; temporal atrophy; rials are associated with improved ease of use, longer- prominent prejowl sulci; and deep forehead lines, naso- lasting results, and minimal adverse effects (AEs) and labial folds, and marionette lines. Characteristically, aging downtime. The aging lower face undergoes characteristic lips also become thinner and flatter with blunting of the vermilion border, Cupid’s bow, and philtral columns. All from the Department of Dermatology, St. Luke’s-Roosevelt Hospital The gradual changes associated with aging often cause Center, New York, New York. Dr. Perez also is from Advanced the face to appear tired and unhappy, which can have DermCare, Danbury, Connecticut. social implications that affect how a person is perceived The authors report no conflicts of interest in relation to this article. by others.1 Soft tissue augmentation with surgical and This article is the first of a 2-part series. The second part will appear minimally invasive procedures has dramatically evolved in a future issue. to help reverse the signs of aging in the lips and lower Correspondence: Anthony M. Rossi, MD, Department of Dermatology, face. Although most dermal fillers are approved by the St. Luke’s-Roosevelt Hospital Center, 1090 Amsterdam Ave, Floor 11, US Food and Drug Administration (FDA) for treatment New York, NY 10025 ([email protected]). of lines and wrinkles only, we encourage a more natural 260 Cosmetic Dermatology® • JUNE 2012 • VOL. 25 NO. 6 www.cosderm.com Copyright Cosmetic Dermatology 2012. No part of this publication may be reproduced, stored, or transmitted without the prior written permission of the Publisher. Soft tiSSue AugmentAtion With DermAl fillerS approach using global assessment to develop an individu- cosmetic indication for Sculptra Aesthetic includes correc- alized approach to volume restoration and rejuvenation. tion of shallow to deep nasolabial fold contour deficiencies In 1893, Neuber2 became one of the first physicians to and other facial wrinkles. Radiesse currently is approved report the use of soft tissue augmentation by filling facial for use in the United States for moderate to severe facial defects with fat removed from a patient’s arms. Since then wrinkles and folds such as nasolabial folds and for the cor- and especially over the last decade, the use of various rection of facial fat loss in patients with human immuno- dermal fillers has exponentially increased as a popular deficiency virus–associated lipoatrophy.9 For treatment of means of cosmetic enhancement and reversing the aging deeper lines or areas where structural support is needed, process. The first bovine collagen filler Zyderm (Allergan, thicker filler materials can optimize outcomes, whereas Inc) was introduced in 19773 and was approved by the thinner fillers are better suited for treatment of superficial FDA in 1981; however, this product was not ideal because rhytides and the superficial dermis. of the short duration of its clinical efficacy and its immu- nogenic potential, which necessitated preinjection skin CONSULTATION testing.4,5 A desire for a lower risk for hypersensitivity and Prior to any cosmetic procedure, the physician and the longer-lasting effects led to the development of human patient should comprehensively discuss potential AEs collagen–derived fillers such as Autologen (Isolagen as well as other possible treatment options. It also is im- Technologies Inc), which was harvested from the patient’s portant to discuss the patient’s desired outcome and to own skin but had a complex production process, and inform the patient of the likely degree of correction that Dermalogen (Collagen Matrix Technologies, Inc), which is possible. Baseline photographs are essential in docu- was derived from tissue banks and introduced in 1998.4-6 menting and discussing any preexisting asymmetries, However, longer-lasting products with a minimal risk irregularities, or scars prior to injection.10 Informed con- for sensitivity were still desired. Introduced in 2003, the sent should be obtained, and rare but potential AEs such CosmoDerm and CosmoPlast (Inamed Corporation) fam- as infection, formation of granulomas or nodules, the ily of fillers was developed based on the technology of Tyndall effect, bruising, persistent numbness, intra- growing a single cell line ofCOS human fibroblastic collagen DERM arterial injection, necrosis, pain, and hematoma formation in culture7; however, these products did not prove to have should be noted. A detailed medical history including any the long-lasting effects desired by both cosmetic surgeons facial nerve disorders, herpes simplex virus infection, and patients, and thus continued distribution has dimin- hypertension, diabetes mellitus, pregnancy, and autoim- ished with the advent of new filler materials. mune disorders should be documented. If applicable, More recently, the FDA’sDo approval of tightly Not cross-linked, antiviral Copy prophylaxis for herpes simplex virus should be nonanimal-stabilized hyaluronic acid (HA) fillers for use prescribed. Once realistic expectations are addressed, an in the United States has revolutionized soft tissue aug- appropriate management plan can be initiated. mentation. Hyaluronic acid can be cross-linked to varying degrees, which determines the size and inherent nature LIP AUGMENTATION of the product. Hyaluronic acid fillers, some containing Noninvasive lip augmentation has become increasingly lidocaine, primarily will be discussed in this article with popular with the development of thinner HA fillers, which regard to their use for augmentation in the lips and lower have become the most commonly used products in this face. The HA fillers Restylane/Restylane L and Perlane/ area.11 When considering augmentation with fillers, a com- Perlane L (Medicis Aesthetics, Inc) as well as Juvéderm prehensive knowledge of the different anatomic compo- Ultra/Ultra Plus/Ultra XC/Ultra Plus XC (Allergan, Inc) nents of the lips and the distinct structures that provide are FDA approved for the correction of moderate to severe both the underlying support and youthful appearance of facial wrinkles and folds such as nasolabial folds, but there lips is imperative. Physicians must consider the following also has been reported success in other off-label indica- factors when assessing the lips: the shape and size of the tions. Recently, the FDA approved Restylane for lip aug- upper and lower lips; the vermilion border; the white roll, mentation in patients older than 21 years. a fine line of pallor skin that accentuates the circumferential The effects of soft tissue augmentation procedures using vermilion skin border; the Cupid’s bow; the philtrum, ex- these newer fillers tend to last for 6 to 12 months,8 though tending from the upper lip to inferior nasal septum; and the satisfactory results may persist for up to 18 months with upper and lower labial tubercles.12-14 It is important to rec- re-treatment. In this article, we discuss the use of poly- ognize signs of aging in the lips (Table) to provide optimal L-lactic acid (PLLA)(Sculptra Aesthetic, sanofi-aventis rejuvenation to the aspects that are most in need of correc- US LLC) and calcium hydroxylapatite (CaHA)(Radiesse, tion and achieve an aesthetically pleasing result.10 The lips Merz Aesthetics, Inc) in the lips and lower face. The can be challenging to treat, as they are a focal point in social www.cosderm.com VOL. 25 NO. 6 • JUNE 2012 • Cosmetic Dermatology® 261 Copyright Cosmetic Dermatology 2012. No part of this publication may be reproduced, stored, or transmitted without the prior written permission of the Publisher. Soft tiSSue AugmentAtion